A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?

Document the infiltration.

Stop the infusion.

Elevate the arm.

Apply a warm compress.

Answer and Explanation

The Correct Answer is B

The correct answer is B.

Stop the infusion. The nurse should stop the infusion immediately to prevent further fluid accumulation and tissue damage. This is a priority action according to the ABCDE principle, which guides nurses to prioritize airway, breathing, circulation, disability, and exposure issues. Infiltration is a complication of IV therapy that occurs when fluid leaks into the surrounding tissue due to dislodgment or puncture of the catheter. The signs and symptoms of infiltration include edema, coolness, pallor, pain, and decreased flow rate at the insertion site.

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Correct Answer is B

Explanation

The correct answer is B. Performing sponge baths until the baby's umbilical cord falls off is a recommended practice to prevent infection and promote healing of the cord stump. The bath water should be warm but not hot, around 85 to 90 degrees Fahrenheit. Talcum powder can irritate the baby's skin and lungs and should be avoided. Alkaline soap can dry out the baby's skin and should be replaced with a mild, pH-balanced cleanser.

A. Administer the client's formula at room temperature. B. Provide the client with low-calorie formula. C. Increase the rate of the client's feeding. D. Switch the client to a formula containing less protein

Correct Answer is A

Explanation

The correct answer is A. Administer the client's formula at room temperature. The nurse should administer the formula at room temperature to reduce gastrointestinal motility and prevent diarrhea.

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A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?

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A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?